Resident-to-resident altercation resulting in physical abuse and injury
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ right to be free from physical abuse when two roommates became involved in a physical altercation. One resident, with a history of cerebral infarction resulting in hemiplegia, hemiparesis, and difficulty walking, and with intact cognition (BIMS 15/15), was seated in a wheelchair in the doorway of the shared room. The other resident, who also had a history of cerebral infarction with hemiplegia and hemiparesis, dementia, communication deficit, difficulty walking, and a history of falls, and who had moderate cognitive impairment (BIMS 10/15), attempted to pass through the doorway and became impatient when unable to do so. According to interviews and documentation, the resident with moderate cognitive impairment pushed the wheelchair of the other resident in an effort to get past. The resident in the wheelchair reported telling the other resident to wait, but the pushing continued, moving the wheelchair into the hallway while the seated resident was resisting. During this interaction, the resident attempting to pass struck the resident in the wheelchair in the right eye, and the resident in the wheelchair responded by reaching back and swatting, which resulted in scratching the other resident. Witness accounts and clinical records confirmed the physical contact and resulting injuries. A fellow resident stated that one resident hit the other in the doorway and that the other resident “clawed back” and scratched the first resident’s face. A CNA reported seeing one resident hitting the other and observed bleeding from scratches on the forehead and neck of the resident with dementia. Change of Condition evaluations documented superficial scratches to the forehead and neck of the resident with dementia and subconjunctival redness of the right eye of the resident in the wheelchair, confirming that both residents sustained physical injury during the altercation.
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